Provider Demographics
NPI:1205098134
Name:BLAKE, REBECCA S I (CNA)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:S
Last Name:BLAKE
Suffix:I
Gender:F
Credentials:CNA
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:S
Other - Last Name:BLAKE
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:CERTIFIED NURSE AID
Mailing Address - Street 1:408 N MO ST
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:OK
Mailing Address - Zip Code:73369
Mailing Address - Country:US
Mailing Address - Phone:580-661-2904
Mailing Address - Fax:
Practice Address - Street 1:408 S 17TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-4236
Practice Address - Country:US
Practice Address - Phone:580-323-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37V350170804101YM0800X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health